Boca Ciega Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Gulfport, Florida.
- Location
- 1414 59th St S, Gulfport, Florida 33707
- CMS Provider Number
- 105271
- Inspections on file
- 24
- Latest survey
- March 25, 2026
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Boca Ciega Center during CMS and state inspections, most recent first.
Two residents were involved in an unwitnessed altercation after a severely cognitively impaired, wheelchair-propelled resident with dementia and aphasia, known by staff to wander and enter other residents’ rooms, went into another cognitively intact resident’s room and put on that resident’s shoes. Video showed the wandering resident entering the room and later exiting with visible facial bleeding and mismatched shoes, while the other resident left the room without visible blood. Progress notes and skin assessments documented multiple new facial injuries and emotional distress in the injured resident. Staff interviews confirmed a longstanding pattern of the injured resident going into other rooms and being redirected without consistent documentation, while facility leadership reported they were unaware of this behavior despite an existing behavior care plan and an abuse prevention policy requiring identification of residents whose behaviors might lead to conflict. This lack of effective supervision and communication led to the resident-to-resident altercation and resulting injuries.
Surveyors identified that the facility did not maintain required documentation for generator testing and maintenance, including missing records for monthly load tests, annual load bank and battery tests, weekly battery voltage checks, annual preventative maintenance, and main breaker testing, as required by NFPA standards.
Two residents in a LTC facility did not receive timely incontinence care, leading to discomfort. Interviews revealed staffing challenges, with CNAs managing high resident loads and being pulled for other duties, causing delays in care. Documentation showed gaps in care provision, and the facility lacked specific policies for ADL and incontinence care.
The facility failed to maintain a clean and sanitary kitchen environment, with observations of dirty trash cans, food trays piled up, dirt and food particles on the walk-in refrigerator floor, and a dirty stove with missing knob covers. Interviews with the CDM and Nursing Home Administrator confirmed awareness of the issues, which violated the facility's cleaning and sanitation policy.
The facility failed to ensure a safe, clean, and homelike environment for residents, with observations of broken furniture, structural damage, and unsanitary bathroom conditions. Maintenance and housekeeping staff confirmed the need for extensive repairs and cleaning.
The facility failed to properly update and review care plans for several residents, leading to inaccuracies in care planning and documentation. This included not reflecting discontinued medications, redundant interventions, and missing care plans for significant physical limitations.
The facility failed to provide appropriate restorative therapy for two residents, leading to deficiencies in their range of motion and mobility. One resident with Multiple Sclerosis was observed without necessary splints, and staff were unaware of their responsibilities. Another resident with encephalopathy had significant limitations in her upper extremities, with no active care plan addressing her ROM needs. The lack of coordination and communication among staff contributed to these deficiencies.
The facility failed to ensure proper infection control during medication administration, PPE usage, and resident hand hygiene. Staff were observed not offering hand hygiene to residents before meals, mishandling PPE, and improperly administering medications, contrary to facility policies.
The facility failed to ensure a resident's call light was consistently within reach, despite the resident's medical conditions requiring easy access. Staff confirmed the call light should be accessible, but it was repeatedly found out of reach, and the facility lacked a policy for call lights.
The facility failed to provide adequate ADL assistance to two dependent residents, resulting in unmet personal hygiene needs. One resident, who is cognitively intact and dependent on staff for personal hygiene, was observed with long, dirty fingernails and thick facial hair despite requesting assistance. Another resident with reduced mobility was observed with knotted hair and overgrown fingernails, and was not engaged in any activities. The facility lacked a policy for ADL care, leading to inconsistent care and documentation.
The facility failed to provide necessary activities for two dependent residents according to their care plans. Observations showed the residents were often in bed, disheveled, and not engaged in activities. Staff interviews revealed that the Activities Director was too busy to conduct activities for dependent residents, and some CNAs did not document refusals or encourage participation.
A resident with end-stage renal disease requiring dialysis did not receive timely post-dialysis vital signs checks and AV fistula assessments as per physician orders. The facility's dialysis communication binder showed inconsistent documentation and lack of timely communication from the dialysis center. The resident reported excessive bleeding from the AV fistula site, but the nursing staff did not check his vital signs or assess the site upon his return.
The facility failed to obtain blood pressures for a resident as required by the physician's order for Hydralazine, a vasodilator. The resident had essential hypertension and a history of cerebral infarction. Blood pressures were only taken once a week instead of every 8 hours, making it impossible to determine the necessity for administering Hydralazine. Additionally, blood pressures were not taken prior to administering other hypertension medications, contrary to the physician's orders.
The facility failed to ensure safe and secure medication storage, did not discard expired medications, and did not label medications with shortened shelf lives with open dates. Observations revealed undated and expired medications, improper storage, and discrepancies in medication administration records.
The facility failed to assess and obtain physician orders for the wounds of two residents, leading to deficiencies in wound care management. One resident had a dressing on a left below the knee amputation that was not changed for several days without a physician order, and another resident had gaps in documentation and physician orders for wound care. The facility's wound care protocol was not followed, resulting in inadequate wound care management.
Failure to Supervise Wandering Resident Leads to Resident-to-Resident Altercation and Injury
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision and prevent resident-to-resident altercation, resulting in injury to a severely cognitively impaired resident. One resident (Resident #5) had a diagnosis that included unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety, encephalopathy, difficulty in walking, and a cognitive communication deficit, with a BIMS score of 0 indicating severe cognitive impairment. This resident was able to self-propel in a wheelchair, wore a wanderguard, and was known by staff to wander, enter other residents’ rooms, and rummage through their belongings. Another resident (Resident #6), cognitively intact with a BIMS score of 14, had multiple medical diagnoses including chronic pain syndrome, neuromuscular dysfunction of bladder, idiopathic progressive neuropathy, generalized anxiety disorder, bipolar disorder, type 2 diabetes, and atherosclerotic heart disease. On the day of the incident, video footage showed Resident #5 in his wheelchair near the exit doors outside Resident #6’s room, touching the wall, and then self-propelling into Resident #6’s room. Approximately ten minutes later, Resident #6 returned to his room in a motorized wheelchair and entered, with the door closing to leave about a one-foot opening. A short time later, Resident #5 exited the room in his wheelchair with a visible stream of blood from his eye down his cheek to his mouth and wearing two different shoes. Staff B, an LPN, was then seen approaching the area and entering a room across from Resident #6’s room before leaving the camera’s view toward the nurses’ station, and Resident #6 later exited his room without visible blood on his person. Progress notes documented that staff observed an altercation between two residents on the hall after one resident was found in another resident’s room touching property and putting on the other resident’s shoes. Verbal escalation occurred, followed by punches being thrown by both residents. Resident #5 was later documented as crying and stating he was “punching and punching,” and was found with injuries including a left eyebrow cut, a left temple hematoma, and an abrasion below the left temple. Staff interviews confirmed that Resident #5 frequently went into other residents’ rooms, did not know where his own room was, and required redirection, although CNAs reported they did not document these room entries. The MDS coordinator confirmed a behavior care plan for wandering into other residents’ rooms had been initiated, and the care plan included interventions such as documenting behaviors, diverting attention, and removing the resident from situations as needed. However, the DON and Nursing Home Administrator stated they were unaware of Resident #5’s behavior of entering other residents’ rooms until after this event, despite the facility’s Abuse Prevention Program policy stating that leadership will identify residents with needs or behaviors that might lead to conflict or abuse/neglect. Additional observations and interviews further illustrated the ongoing wandering behavior and lack of effective supervision. On the survey date, Resident #5 was observed in the dining room with a speech therapist, with visible bruising on the left outer eye area, and the speech therapist described him as oriented only to self, not knowing where his room was, and spending much of the day looking for it. During an interview with an LPN, Resident #5 was again observed at the end of the hall next to the exit doors outside Resident #6’s room, requiring the nurse to run down the hall and redirect him back toward the nurses’ station. CNAs reported that Resident #5 had been going into other residents’ rooms since admission and that they redirected him when observed, but did not document these behaviors. These documented patterns of wandering into other residents’ rooms, combined with the facility leadership’s lack of awareness of the behavior and the unwitnessed altercation that resulted in injury, demonstrate the facility’s failure to ensure adequate supervision and to prevent resident-to-resident altercation as required by its own policies and regulatory standards. The facility’s Abuse Prevention Program policy, last revised in 03/2022, stated that leadership would identify situations in which abuse, neglect, mistreatment, exploitation, or misappropriation may be more likely to occur, including residents with needs or behaviors that might lead to conflict or abuse/neglect. Despite this, the DON and NHA reported they were not aware of Resident #5’s behavior of entering other residents’ rooms, even though multiple staff members, including CNAs and the MDS coordinator, acknowledged this behavior and a behavior care plan had been initiated. The lack of consistent documentation and communication about Resident #5’s wandering and room-entry behavior, combined with the absence of effective supervision to prevent him from entering Resident #6’s room and the subsequent altercation, led directly to the resident-to-resident incident and injuries that formed the basis of the cited deficiency.
Failure to Maintain Generator Testing and Maintenance Documentation
Penalty
Summary
The facility failed to maintain required documentation of generator testing and maintenance in accordance with NFPA 101, NFPA 99, and NFPA 110 standards. During a record review with the Administrator and Maintenance Director, surveyors found that there was no evidence provided for several critical generator tests and maintenance activities. Specifically, documentation was missing for the monthly 30% load test, the annual 1.5-hour load bank test, battery conductance tests, weekly battery voltage tests, annual preventative maintenance, and the annual main breaker test. The Maintenance Director confirmed that the only documentation available was the most recent report from their generator company, which did not include the required records. These findings were discussed with both the Maintenance Director and the Administrator during the exit conference. The lack of documentation for these essential electrical system tests and maintenance activities constitutes a deficiency, as it does not meet the requirements set forth by the referenced NFPA codes. No information about residents or their conditions was included in the report.
Inadequate Incontinence Care Due to Staffing Issues
Penalty
Summary
The facility failed to provide timely incontinence care for two residents, leading to discomfort and potential health risks. Resident #2 reported that his incontinence needs had not been addressed since the previous night, and Resident #1 stated that her last incontinence care was at 3:30 a.m., leaving her wet and uncomfortable. Both residents expressed dissatisfaction with the care they received, highlighting a delay in addressing their needs. Interviews with staff revealed significant staffing challenges that contributed to the deficiency. Staff E, a CNA, was unable to specify the number of residents she was responsible for, indicating a lack of clarity in assignments. Other CNAs reported high resident loads, with some responsible for up to fourteen residents, many of whom required total care. The CNAs expressed that the workload was overwhelming, and the removal of staff to assist in the main dining area further exacerbated the situation, delaying care for residents. The facility's documentation showed gaps in the provision of care, with Resident #1 receiving toileting care only once during the night and no further entries documented. Similarly, Resident #2's care records indicated long intervals between incontinence care. Despite the facility's stated policy of checking residents every two hours, the evidence suggested that this standard was not consistently met. The lack of specific policies for ADL and incontinence care further contributed to the inconsistency in care delivery.
Failure to Maintain a Clean and Sanitary Kitchen
Penalty
Summary
The facility failed to ensure a clean and sanitary kitchen environment, as observed during multiple inspections. On an initial tour of the kitchen, a dirty trash can was found next to the hand washing station, and food trays were piled up on the kitchen sink during meal preparation. Additionally, dirt and food particles were observed on the walk-in refrigerator floor. During a follow-up visit, the kitchen stove was found dirty with grease and missing stove knob covers. An open garbage can was observed next to cooked food on the stove, and the kitchen floor was repeatedly noted to be dirty throughout the survey period. Interviews with the Certified Dietary Manager (CDM) and the Nursing Home Administrator revealed acknowledgment of the cleanliness issues. The CDM admitted that certain areas in the kitchen needed cleaning and that the walk-in refrigerator floor was particularly difficult to clean. The Nursing Home Administrator confirmed that she had discussed the cleanliness issues with the CDM multiple times and found the current state of the kitchen unacceptable. The facility's policy on cleaning and sanitation, effective since September 2012, mandates a clean and sanitary environment, including covered trash cans and sanitized kitchen equipment, which was not adhered to in this instance.
Facility Fails to Maintain Safe and Clean Environment
Penalty
Summary
The facility failed to ensure a safe, clean, and homelike environment for resident rooms and bathrooms over a four-day observation period. Specific deficiencies included broken furniture, such as lopsided drawers and missing doorknobs, as well as structural damage like deep gouges in the drywall and cracked sinks with visible brownish/black substances. Additionally, the facility's bathrooms were found to be in poor condition, with missing tiles, discolored grout, and black substances on shower curtains and caulking. Rusty safety handles and reports of palmetto bugs/roaches further highlighted the unsanitary conditions. These observations were confirmed by the Maintenance Director and the Nursing Home Administrator, who acknowledged the need for repairs and cleaning. The facility's policy on maintaining a safe, clean, and comfortable environment was not adhered to, as evidenced by the numerous deficiencies observed. The Maintenance Director and Environmental District Manager confirmed the unacceptable conditions, noting that the entire building needed auditing and repairs. The Housekeeping Manager also acknowledged the persistent issues with cleanliness and maintenance, such as the recurring rust on safety handles. Photographic evidence was obtained to document these deficiencies, further substantiating the need for immediate corrective action.
Care Plan Deficiencies
Penalty
Summary
The facility failed to revise and review the care plan for Resident #60 with the appropriate staff and professionals. Despite the resident having an intact cognition with a BIMS score of 13 out of 15, there was no evidence of participation in care planning meetings. The care plan goals were revised, but there were no progress notes indicating a care plan meeting had been held. Staff interviews confirmed the lack of documentation and awareness regarding the resident's care plan meetings and invitations, indicating a failure in the care planning process for this resident. Resident #55's care plan was not updated to reflect the discontinuation of psychotropic medications. The resident's care plan still indicated the use of antidepressants, despite the last psychotropic medication, Trazodone, being discontinued in October 2023. Staff interviews confirmed that the care plan should have been resolved when the medication was discontinued, but it remained unchanged, leading to inaccurate care planning for the resident. Resident #1's care plan contained redundant interventions regarding toileting, and the fall care plan was not appropriately updated after a fall incident. The resident was observed on the floor, and staff confirmed that the care plan should have been reviewed and updated with appropriate interventions. Similarly, Resident #47's care plan was not updated to reflect current dietary and catheter orders, leading to potential miscommunication among care staff. Resident #85's care plan lacked an ADL care plan despite the resident's significant physical limitations, as confirmed by staff interviews. The facility's policy emphasized the importance of updating care plans, but this was not adhered to in these cases, resulting in deficiencies in care planning and documentation.
Failure to Provide Appropriate Restorative Therapy
Penalty
Summary
The facility failed to provide appropriate restorative therapy for two residents, leading to deficiencies in their range of motion (ROM) and mobility. Resident #30, diagnosed with Multiple Sclerosis (MS) and other conditions, was observed without the necessary splints that were part of his care plan. Interviews with staff revealed confusion and lack of awareness about the restorative therapy program, with some staff members unaware of their responsibilities or the location of necessary equipment. The Program Manager and other staff members confirmed that the restorative therapy program, known as the Functional Maintenance program, was not being properly implemented or monitored, resulting in Resident #30 not receiving the required care to maintain his ROM. Resident #85, with diagnoses including encephalopathy and abnormalities of gait and mobility, was observed with significant limitations in her upper extremities, unable to open her fingers or extend her arms. The resident's care plan for Activities of Daily Living (ADL) had been resolved, and there was no active plan addressing her ROM needs. Interviews with staff indicated a lack of clarity on who was responsible for providing ROM exercises, with some staff members noticing the resident's decline but not taking appropriate action. The Director of Rehabilitation confirmed the need for an evaluation and planned to request an order from the physician. The facility's failure to properly implement and monitor the restorative therapy program for these residents resulted in a decline in their ROM and mobility. The lack of coordination and communication among staff, as well as the absence of clear ownership of the restorative therapy program, contributed to these deficiencies. The Assistant Director of Nursing acknowledged the issue and indicated that it would be addressed, but at the time of the survey, the deficiencies remained uncorrected.
Infection Control and Medication Administration Deficiencies
Penalty
Summary
The facility failed to ensure proper infection prevention and control practices during medication administration, personal protective equipment (PPE) usage, and resident hand hygiene. Observations revealed that residents were not offered hand hygiene prior to meals, and staff members were seen delivering meal trays without encouraging or assisting residents with hand hygiene. Additionally, an Activities Director was observed using a wet paper towel to clean a resident's hands before assisting with feeding, which is not an appropriate method for hand hygiene. During incontinence care for a resident on Enhanced Precaution Isolation, a CNA was observed rummaging through the resident's closet and leaving the room with the same PPE used during care, contaminating multiple surfaces including a locked linen closet keypad. Another CNA appropriately removed and donned new PPE before continuing care. This incident was reported to the Unit Manager, who acknowledged the breach in protocol and cleaned the contaminated keypad. Medication administration practices were also found to be deficient. An RN was observed handling medication with bare hands and inconsistently using alcohol-based hand rub between tasks. Another RN was seen dropping a pill onto a medication cart and placing it back into a medicine cup, as well as attempting to administer multiple pills at once, resulting in dropped pills being picked up with bare hands and given to the resident. These actions were contrary to the facility's policy on medication administration and hand hygiene, which emphasizes the use of gloves and proper handwashing techniques to prevent infection spread.
Failure to Ensure Call Light Accessibility for Resident
Penalty
Summary
The facility failed to accommodate the needs of Resident #85 by not ensuring the call light was within the resident's reach. On multiple occasions, the call light was observed to be out of reach, either around the bed rail or underneath the resident's shoulder. Despite the resident's inability to reach the call light, staff members had to be reminded to place it within reach, indicating a recurring issue. Interviews with staff confirmed that the call light should always be within the resident's reach, yet this was not consistently maintained for Resident #85. The resident expressed that this issue happens frequently, highlighting a persistent problem in ensuring accessibility to the call light. Resident #85 was readmitted to the facility from an acute care hospital with medical diagnoses including encephalopathy, abnormalities of gait and mobility, lack of coordination, reduced mobility, and muscle wasting and atrophy. Despite these conditions, which necessitate easy access to the call light for assistance, the facility did not have a policy and procedure for call lights. The Director of Nursing and the Nursing Home Administrator both acknowledged that residents should be able to access the call light when needed, yet the deficiency persisted.
Failure to Provide Adequate ADL Assistance
Penalty
Summary
The facility failed to provide adequate ADL assistance to two dependent residents, resulting in unmet personal hygiene needs. Resident #81, who is cognitively intact and dependent on staff for personal hygiene due to paraplegia, was observed with long, dirty fingernails and thick facial hair. Despite requesting assistance multiple times, the resident's needs were not met, as confirmed by staff interviews. The CNA responsible for Resident #81 admitted to being too busy to provide the requested care, and the RN and DON confirmed that staff are expected to report and document any issues with completing ADL tasks, which was not done in this case. Resident #13, who has reduced mobility and requires substantial assistance with personal care, was observed multiple times with knotted hair and overgrown fingernails. The resident was also noted to be disheveled and not engaged in any activities. Interviews with CNAs revealed that while some staff attempted to provide care, others did not document refusals or encourage the resident to participate in ADL care. The DON confirmed that the resident's care plan did not account for refusals of care, and there was a lack of documentation and follow-up on the resident's ADL needs. The facility did not have a policy for ADL care, which contributed to the inconsistency in providing and documenting necessary personal hygiene assistance. The lack of a structured approach and clear documentation led to the neglect of essential ADL care for these residents, highlighting a significant deficiency in the facility's care practices.
Failure to Provide Activities for Dependent Residents
Penalty
Summary
The facility failed to ensure that two residents were provided with activities according to their care plans. Resident #68 was observed multiple times over several days lying in bed, dressed in a nightgown, with her call light out of reach and not engaged in any activities. The resident's care plan indicated that she required staff assistance with activities due to cognitive deficits, but the Activities Director admitted that she was too busy to conduct activities for dependent residents on the 100 hall that week. The Director of Nursing confirmed that residents should have activities according to their care plans, but this was not being met for Resident #68. Resident #13 was also observed multiple times over several days lying in bed, disheveled in appearance, and not engaged in any activities. The resident's care plan indicated that she was fully dependent and required substantial assistance with personal care and activities. Staff interviews revealed that while some CNAs attempted to provide care and activities, others did not document refusals or encourage the resident to participate in activities. The Activities Director stated that she was responsible for activities for the entire resident population but had been too busy to visit dependent residents recently. The facility did not provide their activities policy when requested. The Director of Nursing and the Activities Director both acknowledged that the current system was not meeting the needs of dependent residents, as the Activities Director was unable to conduct one-on-one activities due to being overburdened with other tasks. This led to a failure in providing necessary activities for Resident #68 and Resident #13, as outlined in their care plans.
Failure to Provide Timely Post-Dialysis Assessment and Vital Signs Monitoring
Penalty
Summary
The facility failed to provide timely assessment and vital signs monitoring for a resident who required dialysis care. Resident #53, who has a primary diagnosis of hemiplegia and hemiparesis following cerebral infarction and secondary diagnoses including end-stage renal disease requiring dialysis, did not receive post-dialysis vital signs checks and AV fistula assessments as per physician orders. The review of the resident's dialysis communication binder revealed inconsistent documentation and lack of timely communication from the dialysis center. On multiple occasions, the post-dialysis reports and vital signs were either missing or not documented promptly. On one specific instance, Resident #53 returned from dialysis and reported excessive bleeding from the AV fistula site, which required prolonged direct pressure to stop. Despite this, the nursing staff did not check the resident's vital signs or assess the AV fistula site upon his return. The resident expressed that the nursing staff never checked on his condition post-dialysis. The facility's policy on dialysis management, which includes guidelines for post-dialysis assessment and communication, was not followed, leading to a deficiency in the care provided to the resident.
Failure to Monitor Blood Pressure as Ordered
Penalty
Summary
The facility failed to obtain blood pressures for one resident (#60) as required by the physician's order for the vasodilator Hydralazine. The resident had a diagnosis of essential hypertension and a history of cerebral infarction. The physician's order specified that Hydralazine should be administered every 8 hours as needed for systolic blood pressure greater than 160. However, the Medication Administration Records (MAR) for March and April revealed that blood pressures were only taken once a week, on Sundays, rather than every 8 hours as required. This failure to monitor blood pressure every 8 hours meant that the necessity for administering Hydralazine could not be accurately determined. Additionally, blood pressures were not taken prior to administering other hypertension medications, Hydrochlorothiazide and Metoprolol, as per the physician's orders. The care plan for the resident included interventions such as taking vital signs and administering medications as ordered, but these were not followed correctly. An interview with a Registered Nurse/Unit Manager confirmed that blood pressures should have been taken every 8 hours for the PRN Hydralazine order. The facility's policy on physician orders emphasized the importance of confirming the accuracy of orders and reviewing them daily, but there was no specific policy related to nursing documentation. The Hydralazine order was eventually discontinued on 5/1/24 at 4:01 p.m.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure medications were stored in a safe and secure manner, and did not discard medications after their manufacturer expiration date or label medications with shortened shelf lives with open dates. During an observation, a resident was found with a bottle of eye drops and nasal spray on their bedside table, neither of which were documented in the resident's physician orders. Another resident had a jar of Silver Sulfadiazine cream on their bedside dresser, which was labeled as prescription-only, but the resident could not confirm if they applied the cream themselves. The medication administration records showed discrepancies in the orders and application of the cream. Further observations of the medication carts revealed multiple issues, including undated and expired medications, medications stored improperly, and a lack of proper labeling. For instance, undated Latanoprost eye drops, insulin pens, and vials were found without open dates, and some insulin vials were past their discard dates. Additionally, medications were stored alongside disinfecting wipes, and a bottle of liquid protein was found undated. These findings were confirmed by the staff present during the observations.
Failure to Assess and Obtain Physician Orders for Wounds
Penalty
Summary
The facility failed to assess and obtain physician orders for the wounds of two residents, leading to deficiencies in wound care management. Resident #60 was observed with a dressing on a left below the knee amputation (LBKA) that had not been changed for several days. The dressing was dated 4/28, but no physician order or wound evaluation was found in the resident's records. Staff confirmed that there should have been a change in condition assessment and a physician order for the dressing, but these were not completed. The resident's care plan indicated a risk for developing wounds, but the necessary interventions were not followed. Resident #45 was observed with no open areas on the lower extremities, but staff reported that the area heals and reoccurs, and they were just applying cream. The resident's records showed a history of skin impairments and cellulitis, but there were gaps in documentation and physician orders for wound care. A dressing applied on 1/27 was not documented or ordered, and it remained in place for seven days without proper assessment. The facility's wound care protocol was not followed, and the incident was not substantiated because the wound had not worsened. However, the lack of proper documentation and physician orders indicated a failure in wound care management. The facility's policy on wound prevention and treatment emphasized the importance of documenting wound characteristics and providing necessary treatment to promote healing and prevent infection. However, the facility failed to adhere to this policy for both residents. The lack of proper assessment, documentation, and physician orders for wound care led to deficiencies in the quality of care provided to the residents.
Latest citations in Florida
Surveyors found that the facility’s only commercial cooking hood was not maintained in accordance with NFPA 101 and NFPA 96 requirements. During a kitchen tour with the Maintenance Director, the hood was observed to be not grease tight due to missing fire-resistant caulk, and the Maintenance Director acknowledged this condition at the time of the survey.
Surveyors found that the facility failed to comply with NFPA 99, NFPA 70, and NFPA 1 requirements for electrical equipment when, during a tour with the Maintenance Director, a power strip in the electrical room was observed being used as a permanent power source instead of a dedicated receptacle. The report states that this improper use of a relocatable power tap could lead to electrical hazards for residents and staff, and notes that extension cords and power strips are not to be used as substitutes for fixed wiring under the cited codes.
Surveyors found that the facility did not have documentation showing completion of the required annual 90‑minute test of emergency lighting. During record review and interview, the Director of Facilities confirmed that records of this annual test, required under NFPA 101 sections 19.2.9.1 and 7.9, were not available. This deficiency was cited as affecting all occupants in the event of a fire or other emergency.
Surveyors found that the facility failed to perform and/or document the required annual Duct Detector Differential testing for the fire alarm system in accordance with NFPA 101, NFPA 70, and NFPA 72. During record review and interviews with the Director of Facilities, no documentation could be produced to show that this annual testing had been completed, and the Director acknowledged the lack of records. This deficiency was cited as potentially affecting all occupants in the event of a fire or other emergency.
Surveyors found that the facility failed to perform and/or document required annual testing and exercising of main and feeder circuit breakers in accordance with NFPA 99 and manufacturer recommendations. During record review, no documentation could be produced to show that the annual breaker exercises had been completed, and the Director of Facilities acknowledged this lack of records. This deficiency relates to the essential electrical system that supports life safety and critical branches during emergencies.
Surveyors observed that an adapter was used to power a refrigerator in the kitchen and a refrigerator in the dining room manager's office was plugged into a power strip. The Director of Facilities confirmed both uses, which did not comply with NFPA 99 and NFPA 70 requirements prohibiting adapters and power strips from being used as substitutes for permanent wiring.
Surveyors found that food service operations failed to meet professional food safety standards in both the main and satellite kitchens. In the main kitchen, a cook’s facial hair was not fully covered, the handwashing sink did not initially provide warm water, wet-nested pans and dirty plate domes were stored for use, ice buckets were stained with mold-like discoloration, and the high-temp dishwasher failed to reach the required sanitizing temperature. In the satellite pantry, the dishwasher did not reach required wash temperatures, vents and cabinets above serving dishes had mold-like buildup and residue, floors were damaged and soiled, the dishwasher chemical cabinet was rusted, the AC filter was heavily soiled, the juice dispenser had debris near clean cups, and tray carts contained dirty sheet trays. During tray line observation, salad items were held above 41°F, and a pureed vegetable listed on the menu extension was not available on the line.
Two residents on physician-ordered modified diets (pureed and mechanical soft with nectar-thick liquids) were given Regular Menus listing items such as fresh fruit, salad greens, and grilled cheese that were not compatible with their diet orders. Both residents selected items from these Regular Menus, but the facility either could not provide the chosen foods due to diet restrictions or substituted different items (e.g., canned peach halves instead of fresh fruit), despite the residents’ expressed preferences. The RD and dietetic technician confirmed that Regular Menus were routinely provided to all residents, including those on mechanically altered diets, leading to menu choices that did not align with ordered diet consistencies.
Surveyors found that the facility did not follow physician-ordered therapeutic diets or provide prescribed Magic Cup nutritional supplements for several cognitively impaired residents. A resident on a pureed diet with honey-thick liquids was served a lunch without the ordered pureed vegetable, and tray line review on another day showed no pureed vegetables available despite the menu specifying them. Multiple residents with orders for Magic Cup supplements had these listed on their meal tickets but were instead served other desserts or received no supplement at all, while documentation on the MAR indicated full consumption. Dietary staff acknowledged responsibility for providing Magic Cups but could not explain why residents in the dining room did not receive them.
A resident with intact cognition and multiple cardiac and pulmonary diagnoses had clearly documented DNR orders, including signed advance directive forms and care plan entries confirming her wish to avoid resuscitation. During a cardiac emergency, a CNA found the resident unresponsive and notified an RN, who initiated a code blue response. Several RNs and LPNs transferred the resident to bed and began CPR without first verifying code status, despite one LPN asking and then leaving the room to check the record. Staff interviews and video review showed that chest compressions and use of a bag-valve mask continued for about 12 minutes until EMS arrived, even after staff learned the resident was DNR, and the physician confirmed the resident was already listed as DNR in the system, leading to an Immediate Jeopardy finding for failure to honor advance directives.
Commercial Cooking Hood Not Maintained Grease Tight per NFPA Standards
Penalty
Summary
Surveyors identified a deficiency involving the facility’s commercial cooking facilities. During a tour of the kitchen between 1:00 p.m. and 3:00 p.m. with the Maintenance Director, surveyors observed that the one commercial cooking hood in use was not grease tight. Specifically, the hood was missing required fire-resistant caulk, which is necessary for maintaining a grease-tight seal in accordance with NFPA 96 and NFPA 101 standards. The Maintenance Director acknowledged these findings at the time of observation. The deficiency was cited under NFPA 101 and NFPA 96 requirements for commercial cooking operations, which mandate that cooking equipment and associated hoods be protected and maintained in compliance with these fire and life safety codes.
Plan Of Correction
Preparation and/or execution of this plan does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth on the statement of deficiencies. This plan of correction is prepared and/or executed solely because required. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? No residents were affected by this deficient practice. How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken; Commercial cooking hood system inspected; no additional deficient areas were identified. What measures will be put into place or what systematic changes will you make to ensure that the practice does not recur:Maintenance staff and Dietary staff education on proper use and reporting of issues related to cooking hood system.Verification of scheduled inspections and cleaning of cooking hood system by licensed vendor.How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place:The maintenance director/designee will complete weekly audits of cooking hood system for 4 weeks, then monthly for 2 months to ensure compliance. The findings will be reported to the Quality Assurance Performance Improvement Committee for ongoing compliance. Preparation and/or execution of this plan does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth on the statement of deficiencies. This plan of correction is prepared and/or executed solely because required. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? No residents were affected by this deficient practice. How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken; Commercial cooking hood system inspected; no additional deficient areas were identified. What measures will be put into place or what systematic changes will you make to ensure that the practice does not recur; Maintenance staff and Dietary staff education on proper use and reporting of issues related to cooking hood system. Verification of scheduled inspections and cleaning of cooking hood system by licensed vendor. How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place; The maintenance director/designee will complete weekly audits of cooking hood system for 4 weeks, then monthly for 2 months to ensure compliance. The findings will be reported to the Quality Assurance Performance Improvement Committee for ongoing compliance.
Improper Use of Power Strip as Permanent Power Source in Electrical Room
Penalty
Summary
Surveyors identified a deficiency related to improper use of relocatable power taps (RPTs) and power strips in violation of NFPA 99, NFPA 70, and NFPA 1 requirements. During a facility tour conducted between 10:00 a.m. and 12:00 p.m. with the Maintenance Director, surveyors observed one power strip in the electrical room being used as a source of permanent power instead of being connected to a dedicated receptacle. The report notes that this use did not comply with standards that require extension cords and power strips not be used as a substitute for fixed wiring and that they be used only under specified conditions. The deficiency specifically concerns the facility’s failure to ensure that RPTs are maintained and used in accordance with NFPA 99 (2012 Edition) sections 10.2.3.6 and 10.2.4, and NFPA 70 (2011 and 2020 Editions) provisions governing flexible cords and temporary wiring, as well as NFPA 1 (2021 Edition) sections 11.1.2.2, 11.1.4.1, and 1.4.1. The report states that this condition could lead to electric hazards for residents and staff. No individual resident cases, medical histories, or specific clinical conditions are described in connection with this deficiency.
Plan Of Correction
What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? No residents were affected by this deficient practice. How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken; Facility wide audit of electrical rooms was conducted to identify improper use of power strips. No additional concerns were identified. What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur; The facility completed education reinforcing compliance with electrical safety requirements in accordance with National Fire Protection Association. How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place: The maintenance director/designee will complete random electrical safety audits 2 times per week for 4 weeks, then monthly to ensure compliance with electrical safety standards. The findings will be reported to the Quality Assurance Performance Improvement Committee for ongoing compliance. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? No residents were affected by this deficient practice. How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken; Facility wide audit of electrical rooms was conducted to identify improper use of power strips. No additional concerns were identified. What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur; The facility completed education reinforcing compliance with electrical safety requirements in accordance with National Fire Protection Association. How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place; The maintenance director/designee will complete random electrical safety audits 2 times per week for 4 weeks, then monthly to ensure compliance with electrical safety standards. The findings will be reported to the Quality Assurance Performance Improvement Committee for ongoing compliance.
Failure to Document Required Annual 90‑Minute Emergency Lighting Test
Penalty
Summary
Surveyors identified a deficiency related to emergency lighting when, during record review and staff interview between 11:30 AM and 3:00 PM with the Director of Facilities, the facility was unable to provide documentation that the required annual 90‑minute testing of emergency lighting had been performed. The Director of Facilities acknowledged that there was no documentation available to show completion of this annual 90‑minute emergency lighting test, as required by NFPA 101 (2012 and 2021 editions), sections 19.2.9.1 and 7.9. This failure to document the annual emergency lighting test was cited as a noncompliance that could affect all occupants of the facility in the event of a fire or other emergency. No specific residents, medical histories, or clinical conditions were mentioned in the report; the deficiency pertains to facility-wide life safety systems and their required testing and documentation.
Plan Of Correction
Emergency Lighting CFR(s): NFPA 101 Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance and Soley because it is required Emergency Lighting K0291 The facility immediately conducted a comprehensive inspection of all emergency lighting systems. On The Director of Facilities performed the required 90-minute annual testing of all emergency lighting units. Documentation of testing has been completed and is maintained on-site. 2. All areas of the facility were considered at risk due to lack of documented annual testing. A full facility-wide audit of all emergency lighting units was completed on by the Director of Facilities to ensure compliance. 3. The facility implemented a preventative maintenance schedule to ensure annual 90-minute emergency lighting testing is completed in accordance with NFPA 101 (2012), Section 7.9. A log tracking system has been developed to document all required testing. The Director of Facilities/designee will receive re-education on Life Safety Code requirements and documentation standards. 4. The Director of Facilities will review fire alarm testing records quarterly for 12 months, will present the findings for 12 months at Quality Assurance Performance Improvement (QAPI) meetings to confirm inspections have taken place. During and at the conclusion of the twelve months, the QAPI committee will re-evaluate and initiate necessary action or extend the review period. The Administrator is responsible for confirming implementation and ongoing compliance with the components of the Plan of Correction, and resolving variances that may occur. The Administrator is responsible for confirming the status of this Plan of Correction is reviewed and discussed at QAPI meetings and action initiated if required. Emergency Lighting CFR(s): NFPA 101 Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance and Soley because it is required Emergency Lighting K0291 The facility immediately conducted a comprehensive inspection of all emergency lighting systems. On The Director of Facilities performed the required 90-minute annual testing of all emergency lighting units. Documentation of testing has been completed and is maintained on-site. 2. All areas of the facility were considered at risk due to lack of documented annual testing. A full facility-wide audit of all emergency lighting units was completed on by the Director of Facilities to ensure compliance. 3. The facility implemented a preventative maintenance schedule to ensure annual 90-minute emergency lighting testing is completed in accordance with NFPA 101 (2012), Section 7.9. A log tracking system has been developed to document all required testing. The Director of Facilities/designee will receive re-education on Life Safety Code requirements and documentation standards. 4. The Director of Facilities will review fire alarm testing records quarterly for 12 months, will present the findings for 12 months at Quality Assurance Performance Improvement (QAPI) meetings to confirm inspections have taken place. During and at the conclusion of the twelve months, the QAPI committee will re-evaluate and initiate necessary action or extend the review period. The Administrator is responsible for confirming implementation and ongoing compliance with the components of the Plan of Correction, and resolving variances that may occur. The Administrator is responsible for confirming the status of this Plan of Correction is reviewed and discussed at QAPI meetings and action initiated if required.
Failure to Perform and Document Annual Duct Detector Differential Testing
Penalty
Summary
Surveyors identified a deficiency related to the facility’s fire alarm system testing and maintenance, specifically the required annual Duct Detector Differential testing. During record review conducted between 11:30 AM and 3:00 PM, surveyors requested documentation demonstrating that this annual testing had been completed in accordance with NFPA 101 (2012 and 2021 editions), NFPA 70, and NFPA 72. The facility was unable to produce records showing that the Duct Detector Differential testing had been performed as required. In an interview conducted during the same time frame, the Director of Facilities acknowledged that the facility failed to provide documentation of the annual Duct Detector Differential testing. The deficiency was cited under NFPA 101 2012 (19.2.9.1, 7.9) and NFPA 101 2021 (19.2.9.1, 7.9), indicating noncompliance with the standards that require fire alarm detection systems, including duct detectors, to be tested and maintained annually. The report notes that this deficiency could affect all occupants of the facility in the event of a fire or other emergency.
Plan Of Correction
Fire Alarm System - Testing and Maintenance CFR(s): NFPA 101 Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance and Soley because it is required Fire Alarm System - Testing and Maintenance K0345 1. On The facility a certified fire alarm vendor to perform annual duct detector differential testing. All required testing has now been completed and documented. 2. All residents and staff were considered at risk due to lack of documented testing. A facility-wide review of all fire alarm components was conducted on 3. The facility established a service agreement to ensure all fire alarm testing (including duct detectors) is completed annually per NFPA 72 and NFPA 101 requirements. A compliance calendar has been implemented with alerts for required inspections and testing. The Director of Facilities/designee has been re-educated on required testing intervals and documentation. 4. The Director of Facilities or designee will audit for 3 months all documentation for the annual testing and inspection of the duct detector pressure differential test. The Director of Facilities will present the findings of site inspections for 3 months at Quality Assurance Performance Improvement (QAPI) meetings to confirm inspections have taken place. During and at the conclusion of the three months, the QAPI committee will re-evaluate and initiate necessary action or extend the review period. The Administrator is responsible for confirming implementation and ongoing compliance with the components of the Plan of Correction, and resolving variances that may occur. The Administrator is responsible for confirming the status of this Plan of Correction is reviewed and discussed at QAPI meetings and action initiated if required Fire Alarm System - Testing and Maintenance CFR(s): NFPA 101 Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance and Soley because it is required Fire Alarm System - Testing and Maintenance K0345 1. On The facility a certified fire alarm vendor to perform annual duct detector differential testing. All required testing has now been completed and documented. 2. All residents and staff were considered at risk due to lack of documented testing. A facility-wide review of all fire alarm components was conducted on. 3. The facility established a service agreement to ensure all fire alarm testing (including duct detectors) is completed annually per NFPA 72 and NFPA 101 requirements. A compliance calendar has been implemented with alerts for required inspections and testing. The Director of Facilities/designee has been re-educated on required testing intervals and documentation. 4. The Director of Facilities or designee will audit for 3 months all documentation for the annual testing and inspection of the duct detector pressure differential test. The Director of Facilities will present the findings of site inspections for 3 months at Quality Assurance Performance Improvement (QAPI) meetings to confirm inspections have taken place. During and at the conclusion of the three months, the QAPI committee will re-evaluate and initiate necessary action or extend the review period. The Administrator is responsible for confirming implementation and ongoing compliance with the components of the Plan of Correction. The Administrator is responsible for confirming the status of this Plan of Correction is reviewed and discussed at QAPI meetings and action initiated if required
Failure to Perform and Document Annual Main and Feeder Breaker Testing
Penalty
Summary
The deficiency involves the facility’s failure to perform and document required annual maintenance and testing of the main and feeder circuit breakers in accordance with NFPA 99 and manufacturer recommendations. During a record review conducted between 11:30 AM and 3:00 PM, surveyors requested documentation of the annual main and feeder breaker exercise. The facility was unable to provide records demonstrating that this testing and exercising had been completed as required. In interviews conducted during the same time frame, the Director of Facilities acknowledged that the facility did not have documentation showing that the annual main and feeder breaker exercise was performed according to manufacturer recommendations. The report notes that this failure to comply with NFPA 99 (2012 and 2021 editions, Sections 6.4.4 and 6.5.4) could affect all occupants of the facility in the event of a fire or other emergency, and that written records of maintenance and testing are required to be maintained and readily available.
Plan Of Correction
Electrical Systems - Essential Electric System CFR(s): NFPA 101 Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance and Soley because it is required Electrical Systems - Essential Electric System Maintenance and Testing K0918 1. On A licensed electrical contractor performed the annual main and feeder breaker testing/exercising in accordance with manufacturer recommendations. Documentation has been completed and is maintained on-site. 2. All residents were considered at risk due to lack of documented testing. A full review of the essential electrical system was conducted on 3. A preventative maintenance program has been implemented to ensure that annual breaker testing is completed per NFPA 99 (2012). The facility has incorporated electrical system testing into its environmental compliance tracking system. The Director of Facilities/designee received re-education on NFPA requirements. 4. The Director of Facilities will audit electrical system maintenance logs quarterly for 12 months. Inspections have taken place. During and at the conclusion of the three months, the QAPI committee will re-evaluate and initiate necessary action or extend the review period. The Administrator is responsible for confirming implementation and ongoing compliance with the components of the Plan of Correction, and resolving variances that may occur. The Administrator is responsible for confirming the status of this Plan of Correction is reviewed and discussed at QAPI meetings and action initiated if required. Electrical Systems - Essential Electric System CFR(s): NFPA 101 Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance and Soley because it is required Electrical Systems - Essential Electric System Maintenance and Testing K0918 1. On A licensed electrical contractor performed the annual main and feeder breaker testing/exercising in accordance with manufacturer recommendations. Documentation has been completed and is maintained on-site. 2. All residents were considered at risk due to lack of documented testing. A full review of the essential electrical system was conducted on . 3. A preventative maintenance program has been implemented to ensure that annual breaker testing is completed per NFPA 99 (2012). The facility has incorporated electrical system testing into its environmental compliance tracking system. The Director of Facilities/designee received re-education on NFPA requirements. 4. The Director of Facilities will audit electrical system maintenance logs quarterly for 12 months. Inspections have taken place. During and at the conclusion of the three months, the QAPI committee will re-evaluate and initiate necessary action or extend the review period. The Administrator is responsible for confirming implementation and ongoing compliance with the components of the Plan of Correction, , and resolving variances that may occur. The Administrator is responsible for confirming the status of this Plan of Correction is reviewed and discussed at QAPI meetings and action initiated if required.
Improper Use of Adapters and Power Strips for Refrigerators
Penalty
Summary
The deficiency involves improper use of electrical adapters and power strips as substitutes for permanent wiring, in violation of NFPA 99 and NFPA 70 requirements. During an observation with the Director of Facilities, surveyors found that an adapter was being used to power a refrigerator in the kitchen. The Director of Facilities acknowledged that an adapter was in use for this refrigerator, contrary to the standards that prohibit adapters from being used in place of fixed wiring. In a separate observation with the Director of Facilities, surveyors identified that a refrigerator in the dining room manager's office was plugged into a power strip. The Director of Facilities acknowledged that a power strip was being used for this refrigerator. These findings showed that the facility was not complying with NFPA 99 provisions that require power strips and adapters not be used as substitutes for permanent wiring for such equipment.
Plan Of Correction
Formatted text (without <text> tags or quotes): Electrical Equipment - Power and Extension Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance and Soley because it is required Electrical Equipment - Power and Extension K0920 1. On The adapter in the kitchen refrigerator and the power strip in the dining room manager's office were immediately removed. All equipment was plugged directly into approved wall outlets. 2. On A facility-wide inspection was conducted by The Director of Facilities to identify improper use of power strips and adapters. Any non-compliant items were removed immediately. 3. On Staff were educated on proper electrical safety practices, including prohibited use of extension and adapters. Routine environmental rounds now include electrical safety checks. 4. The Director of Facilities/designee will conduct monthly environmental rounds for 3 months, then quarterly thereafter. Quality Assurance Performance Improvement (QAPI) meetings to confirm inspections have taken place. During and at the conclusion of the three months, the QAPI committee will re-evaluate and initiate necessary action or extend the review period. The Administrator is responsible for confirming implementation and ongoing compliance with the components of the Plan of Correction, and resolving variances that Continued from page occur. The Administrator is responsible for confirming the status of this Plan of Correction is reviewed and discussed at QAPI meetings and action initiated if required. Electrical Equipment - Power and Extension CFR(s): NFPA 101 Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance and Soley because it is required Electrical Equipment - Power and Extension K0920 1. On The adapter in the kitchen refrigerator and the power strip in the dining room manager's office were immediately removed. All equipment was plugged directly into approved wall outlets. 2. On A facility-wide inspection was conducted by The Director of Facilities to identify improper use of power strips and adapters. Any non-compliant items were removed immediately. 3. On Staff were educated on proper electrical safety practices, including prohibited use of extension and adapters. Routine environmental rounds now include electrical safety checks. 4. The Director of Facilities/designee will conduct monthly environmental rounds for 3 months, then quarterly thereafter. Quality Assurance Performance Improvement (QAPI) meetings to confirm inspections have taken place. During and at the conclusion of the three months, the QAPI committee will re-evaluate and initiate necessary action or extend the review period. The Administrator is responsible for confirming implementation and ongoing compliance with the components of the Plan of Correction, and resolving variances that may occur. The Administrator is responsible for confirming the status of this Plan of Correction is reviewed and discussed at QAPI meetings and action initiated if required.
Food Safety and Sanitation Deficiencies in Main and Satellite Kitchens
Penalty
Summary
Surveyors identified multiple failures to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in both the main kitchen and a satellite pantry kitchen. In the main kitchen, a cook’s beard cover did not fully cover all facial hair, and the handwashing sink initially did not provide warm water until the Executive Director manually adjusted a valve under the sink. In the pot washing area, full-sized steam table pans were stacked while still wet, and more than five plate domes with stuck-on food particles were found piled in the tray line area ready for use, indicating they had not been properly washed. Two large ice buckets were stained with black and grey mold-like discoloration and white wear marks. The high-temperature dishwashing machine in the main kitchen was run three times but failed to reach the required 180°F rinse temperature, only reaching 172°F, meaning dishes were not properly sanitized. In the second-floor satellite pantry kitchen, the high-temperature dishwashing machine was also run three times and failed to meet required wash temperatures, reaching only 139°F instead of the required 150–165°F, so dishes were not properly cleaned and sanitized. Additional sanitation and maintenance issues were observed, including a vent above serving dishes with a mold-like accumulation, broken and soiled cabinets above serving dishes with residue on the handles, and pantry floors with cracked, broken, and missing tiles with debris or residue buildup. The dishwasher chemical cabinet lock was rust-laden, the AC filter was covered with dark grey soot and dust, the juice dispenser with clean cups nearby had debris on top, and tray delivery carts contained large sheet trays with residue and stuck-on food debris. During a tray line observation, chopped tomatoes and sliced avocados on the salad line were held at 44°F and 45°F respectively, above the required 41°F or less, and the menu extension listed pureed peas for a pureed diet, but no pureed vegetable was present on the line.
Plan Of Correction
Food Procurement, Store/Prepare/Serve-Sanitary CFR(s): 483.60(i)(1)(2) §483.60(i) Food safety requirements. Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance and Soley because it is required F0812 1. All identified sanitation issues were corrected on Hot water valve was fixed immediately by maintenance team Steam table pan wet nesting was corrected The 5 plate domes that were dirty were taken to the dishwasher to be washed Stained ice buckets were replaced with new ones Dishwashing machine not reaching temperature for rinse cycle was fixed by Eco lab the same day Team member was provided education and in-service on proper use of beard guard. Corrected on [R] 2.Identified issues from satellite Kitchen were corrected on [R] Dishwashing machine not reaching temperature for rinse cycle was fixed by Eco lab the same day The vent located above the serving dishes was cleaned by maintenance team The cabinets were cleaned immediately The floors of the pantry area were observed with broken, cracked, missing tiles, with buildup residue and debris. Maintenance director made aware in the process of getting replaced. The locking mechanism of the dishwasher chemical cabinet is rust laden. Laden removed and in the process of being replaced. The AC filter was cleaned by maintenance team Th juice dispenser was cleaned by dietary aide The large delivery trays with residue and food debris were discarded 3. Issues identified during Tray line observation were corrected: The chopped tomatoes and sliced avocados were discarded Pureed vegetable was added to the line. Inservice on serving all food groups, starches, protein and vegetables to residents on texture modified diet order. Inservice provided to all dietary aides Inservice on maintaining and holding temperatures for ready to eat foods. Inservice provided to all cooks and dietary aides Daily sanitation rounds will be conducted by the Certified Dietary manager /designee for one week. Weekly for 2 months. 4. The Certified Dietary Manager/Executive Chef/designee will report the findings of the above observations and audits to the monthly QAPI Committee. The Administrator is responsible for confirming implementation and compliance of this POC and and resolving any variances that may occur.
Failure to Honor Diet-Appropriate Menu Choices for Residents on Modified Diets
Penalty
Summary
The facility failed to provide residents with menu choices that matched their physician-ordered diet textures and liquid consistencies. One resident with severe cognitive impairment had a physician order for a controlled diet with pureed texture and honey-thick liquids. During a noon meal observation, this resident’s meal ticket was stapled to a Regular Menu listing items such as lettuce and tomato salad, stir-fried vegetables, and a grilled cheese sandwich, none of which were appropriate for the resident’s ordered diet. The Registered Dietitian and the Dietetic Technician confirmed that Daily Menu printouts with Regular Menu options were provided to all residents, including those on mechanically altered diets, resulting in residents being offered choices that could not be honored due to diet restrictions. Another resident with moderate cognitive impairment had a physician order for a mechanical soft diet with nectar-thick liquids. This resident’s lunch tray ticket was also stapled to a Regular Menu that included salad greens, which are not allowed on a mechanical soft diet. On a separate breakfast observation, the same resident’s Regular Menu included fresh fruit as a choice, which the resident circled, but the tray contained canned peach halves instead. The resident stated she wanted her chosen fresh fruit rather than the peaches and reiterated her food preferences during the interview. Photographic evidence was obtained to document these discrepancies between ordered diets, menu offerings, and the food actually provided.
Plan Of Correction
Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance and Soley because it is requiredF05501. Resident #54 and Resident #56 were immediately assessed by the Registered Dietitian (RD) & CDM (Certified Dietary Manager) for food preferences on Residents #54 and #56 were offered meal choices consistent with the prescribed diet. No adverse outcomes were identified. 2. 100% audit of all residents with therapeutic diets was completed on [R] by CDM to ensure menus and meal selections consistent with physician-ordered diets.On [R] , CDM provided in-service provided to dietary aides, certified nursing assistants, nurses, managers on new selective menu processes. 3. The facility implemented a diet-specific menu system and pre-meal diet verification process by reviewing the diet in tray ticket program IMPAC and PCC. Copies of the menus to be provided as part of the audits.Diet Menu was revised to include a mechanically altered diet to be consistent with physician orders. Therapeutic diets menus are available and offered to each resident according to physician orders. The Dietary Manager or designee will conduct weekly audits of 4 residents on therapeutic diets x 4 weeks then monthly x 2months, to verify the correct menu is offered and served. 4. The Dietary Manager or designee will report findings at the monthly QAPI meeting. The Administrator is responsible for confirming implementation and compliance with this POC and [R] , and resolving any variances that occur.
Failure to Follow Therapeutic Diet Orders and Provide Prescribed Nutritional Supplements
Penalty
Summary
The deficiency involves the facility’s failure to follow physician-ordered therapeutic diets and prescribed nutritional supplements for multiple residents. One resident with severe cognitive impairment and a physician’s order for a controlled diet with pureed texture and honey-thick liquids was observed at lunch without the ordered pureed vegetable; her plate contained only pureed chicken, a pureed starch, and possibly a pureed bread, all covered in gravy. The pureed menu for that meal listed broccoli as the vegetable, and a subsequent tray line observation on another day showed no pureed vegetables available, despite the pureed menu specifying pureed peas. The dietary manager and registered dietitian were informed of the missing pureed vegetables, and photographic evidence was obtained. The facility also failed to provide ordered Magic Cup nutritional supplements as prescribed. One resident with severe cognitive impairment and a care plan addressing risk for compromised nutritional status had a physician’s order for a 4 oz Magic Cup on day and evening shifts with lunch and dinner; during a breakfast observation, the meal ticket listed Magic Cup, but none was provided. Another resident with moderate cognitive impairment had a physician’s order for a 4 oz Magic Cup with lunch; during lunch observation, the meal ticket indicated Magic Cup, but the resident was served chocolate ice cream and ate coconut cream pie for dessert instead. The MAR documented 100% consumption of a Magic Cup on two consecutive days, despite the observed failure to provide it. During interviews, the RD and dietary manager explained that Magic Cups were to be provided by dietary staff either on trays or via the dessert/ice cream cart, but they could not explain why residents in the dining room did not receive the ordered supplements. Photographic evidence was obtained of these occurrences.
Plan Of Correction
Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance and Soley because it is required F0803 1. Upon identification, resident #54 was given pureed vegetables. Residents #23, #39, and #54 were given Magic Cup supplements as ordered. On [R] CDM re-educated team members on supplement delivery including proper documentation and confirming that pureed diet being served matches what is listed on spread sheet. Dietary aides' morning and evening shifts are accountable for serving all food groups including vegetables when serving puree meals to residents. 2. A 100% audit of all residents with therapeutic diets and/or supplements was completed on [R] by Certified Dietary Manager. 3. A tray line checklist and diet/supplement reconciliation process between dietary and nursing were implemented by [R]. RD oversight of menu compliance was initiated. The Certified Dietary Manager or designee will audit food tray weekly x 4 weeks then weekly x 2 months. 4. The Certified Dietary Manager/Designee will report on the findings at the monthly QAPI meeting. The Administrator is responsible for confirming implementation and compliance with this POC and [R], and resolving any variances that may occur.
Failure to Verify and Honor DNR Order Before Initiating CPR
Penalty
Summary
The deficiency involves the facility’s failure to honor a resident’s clearly established Do Not Resuscitate (DNR) status during a cardiac emergency. The resident had multiple medical diagnoses, including cerebral infarction, COPD, cardiomyopathy, atherosclerotic heart disease, a nonrheumatic mitral valve disorder, cognitive communication deficit, and immunodeficiency. The medical record contained DNR orders created on two separate dates with no end dates, a DNR document signed by the resident and a nurse practitioner, and a 3008 form listing the resident’s advance directive as DNR. The resident’s MDS showed a Brief Interview for Mental Status score of 15, indicating intact cognition, and progress notes documented that the difference between DNR/no CPR and full code had been explained over 30 minutes, after which the resident chose DNR and reiterated to social services that she did not want to be resuscitated or undergo chest compressions. On the day of the incident, a CNA assigned to the resident checked on her and found her sitting in a wheelchair and unresponsive despite multiple verbal attempts to rouse her. The CNA notified the RN, who obtained a blood pressure machine, entered the room, then ran out to the nurses’ station, after which a code blue was paged over the intercom. The RN returned with a crash cart, and additional nursing staff, including RNs and LPNs, entered the room. Staff described transferring the unresponsive resident from the wheelchair to the bed and beginning chest compressions. Multiple staff members reported that when one LPN asked about the resident’s code status, no one in the room knew it at that time, and that this LPN left the room to verify the code status while CPR was already in progress. Interviews and video review confirmed that CPR was initiated and continued for approximately 12 minutes before EMS arrived, despite the resident’s existing DNR orders. Several nurses, including those who arrived after CPR had started, acknowledged that they did not check the resident’s code status before assisting with chest compressions or using a bag-valve mask. Staff later reported that the LPN who checked the record returned and announced that the resident was a DNR, yet compressions continued until EMS arrived. The physician stated that the resident was already in the system as a DNR and that staff were expected to check code status before performing CPR. The DON and regional nurse consultant confirmed, based on interviews and camera review, that staff failed to confirm the resident’s code status prior to initiating CPR and that CPR was performed against the resident’s wishes, leading surveyors to determine that this failure resulted in Immediate Jeopardy.
Removal Plan
- Implemented a revised admission/readmission process requiring an Advance Directive discussion form to be completed by the licensed nurse upon admission or with change in advance directives, with follow-up by Social Services.
- Reviewed Advance Directive discussion forms in the daily clinical meeting with the Interdisciplinary Team.
- Conducted a huddle on units after the clinical meeting to discuss any changes in advance directives/code status.
- Placed signage on each crash cart stating: "Stop check physician order prior to starting Cardiopulmonary Resuscitation."
- Implemented the "It Takes Two" process requiring two licensed nurses to verify code status/advance directives prior to initiation of CPR.
- Initiated an internal investigation including resident record review, staff interviews, and notification to the physician and resident representative.
- Suspended and terminated the assigned nurse and reported the nurse’s license to the licensing board.
- Suspended and terminated an additional nurse who responded and participated in initiation of CPR and reported the nurse’s license to the licensing board.
- Suspended two additional nurses pending investigation and returned them to work with disciplinary action, education on ANE/honoring advance directives, and participation in a code blue drill.
- Conducted a 100% audit of all current residents’ code status and care plans.
- Conducted a 100% audit of crash carts to ensure all required items were present.
- Reviewed CPR cards for identified nurses to confirm validity and inclusion of in-person skills competencies.
- Held an ad hoc QAPI meeting with Administrator, DON, Medical Director, and department heads.
- Completed an audit of residents discharged, transferred to the hospital, or expired to verify advance directives were honored.
- Provided staff education for licensed/certified staff on medical emergency response and communication of advance directives and code status, following physician orders related to advance directives, the "It Takes Two" verification process, and CNA roles during code blue.
- Provided all-staff education on Abuse, Neglect and Exploitation/Resident Rights with focus on honoring advance directives.
- Completed honoring advance directives attestation with licensed nursing staff.
- Completed physician orders education for licensed nursing staff.
- Completed medical emergency response and communication of code status education for licensed nursing staff.
- Completed ANE/Resident Rights education for all staff.
- Completed advance directives posttest for licensed staff.
- Completed ANE/Resident Rights posttest for all staff.
- Completed code blue process/"It Takes Two" education for licensed nursing staff.
- Began code blue drills every shift and required licensed nurses to attend a mock code blue quality assurance drill prior to working.
- Completed CNA roles-in-code-blue training.
- Completed quality reviews validating staff competencies for completed education.
- Completed quality reviews of newly admitted residents to verify completion of the advance directive discussion form.
- Implemented Director of Clinical Services chart review of residents who expire at the facility or are transferred to the hospital after a cardiac event to verify advance directives were followed.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
